A Gastroenterologist’s Guide to Endoscopic Tattooing Methods

A Gastroenterologist’s Guide to Endoscopic Tattooing Methods

MARCH 1, 2021 | There’s no doubt about the effectiveness of endoscopic tattoos as an integral tool for long-term clinical surveillance and surgical localization. Tattooing has proven to both decrease time spent in the operating room1 and greatly improve tumor localization.2 Not to mention, it’s also included in the 2020 Recommendations by the US Multi Society Task Force on Colorectal Cancer for Endoscopic Removal of Colorectal Lesions and ESGE’s Guidelines for EMR and Polypectomy4

So it might surprise you to learn that the methods for endoscopic tattooing are not part of the core surgical curriculum at most medical schools. Not only that, even when it is taught, it’s rarely reinforced with additional training after medical school. And a lack of standardized guidelines for the procedure make it even more of a challenge to get physicians on the same page about when and why to tattoo.

Understandably that leaves medical professionals with a lot of questions about this vital piece of the fight against colon cancer. One of the most notable among these questions relates to the tattoo process. What methods are used to effectively and reliably tattoo for clinical surveillance and surgical localization?

Two Tattoo Techniques

Most use one of the following methods:

The Bleb Technique – The bleb technique is recommended. In this method, a bleb of saline is first injected into the submucosa in four quadrants distal to the tumor (2-3 cm from the lesion). The tattoo is then injected (0.5 to 0.75 mL) into each of the blebs.5

The Direct Method – In the direct method, the tattoo is injected directly into the submucosa, without the use of a saline bleb.

And bear in mind that no matter the technique, an effective endoscopic tattoo requires:

  • * Careful insertion of the needle into the submucosal plane at a 30-45° angle.
  • * Closely monitored and controlled injection to avoid accidental injection into the peritoneal cavity and diffuse intra-abdominal staining, which can be potentially misleading during surgery.6


Also, remember to not tattoo directly into or underneath the lesion.

In “New 2020 Guidelines for Endoscopic Removal of Colorectal Lesions” you’ll find answers to frequently asked questions about endoscopic tattooing, get a closer look at the most common methods for tattooing, and learn more about the latest tool in the fight against colon cancer. Get your copy here:

Get The Guide

1 –  Arteaga-Gonzalez I, et. al., The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study. World J Surg. 2006. 30(4):605–611.
2 – Askin MP, Waye JD, Fiedler L, Harpaz N. Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointestinal Endoscopy. 2002;56(3):339-342. doi:10.1067/mge.2002.126905.
3 –  Kaltenbach et al. Endoscopic Removal of Colorectal Lesions – Recommendations by the US Multi Society Task Force on Colorectal Cancer. Feb 2020
4 – Ferlitsch M, Moss A, Hassan C, etal. Colorectal polypectomy and endoscopic mucosal resection (EMR): ESGE Clinical Guideline. 2017.
5 – Spot® Ex Endoscopic Tattoo Instructions for Use. (2018). [ebook] GI Supply. Available at: https://spotextattoo.com/wp-content/uploads/2018/01/Spot-Ex-Instructions-For-Use-IFU-for-web-G45-006-Rev-2.pdf.
6 – Rex DK. Driving patient safety with endoscopic tattooing. Gastroenterology and Endoscopy News. 2015 May.